Examining the Science Behind the Looming Doc Shortage

It's not a matter of if, it's a matter of how much.

That there will be a doctor shortage in the next decade isn't up for debate. It's fact. What's less certain is how many doctors we will be short.

According to the HHS' Health Resources and Services Administration (HRSA) there will be a shortage of 20,400 primary-care physicians by 2020. However, the American Association of Medical Colleges' (AAMC) projection looked at all physicians and found the shortage ranges between 61,700 and 94,700 physicians.

AAMC's projections have varied over the years and the numbers are updated every year. At one point the shortage projection was as high as 124,000 full-time physicians. Physicians Practice talked to Janis Orlowski, a physician and chief health care officer at AAMC about the projections, why the numbers have varied, what can be done to solve the shortage, and more.

Below are excerpts from the interview.

Physicians Practice: The numbers for the projected physician shortage have fluctuated over the last few years, how did you come up with this latest figure?

Janis Orlowski: We work with a company called IHS and they have a process called micro simulation. They look at certain types of people, for instance, old white men across the U.S., and figure out how many times they see a primary-care doctor or a specialist, what kind of specialists they see, etc. They do these micro simulations looking at people in different ways. They look at differences in accessing care [across the country]. Then with that information, they say, "This is what current utilization of physician practices are for those people." In essence, they add them up and come up with a number.

We then took that information [and made projections using scenarios derived from] two specific data points. Millennial physicians work slightly less hours than their older counterparts. We asked, "What if that continues over the next 10 years, what will that look like?" We also know during the financial downturn from 2008-2013, physicians tended to work two years longer than the average time they'd work until retirement. They pushed off physician retirement. We looked at the scenario if that continues … and they continue to work two years longer. Or, we looked at what would happen if they retired in the traditional time period [from before]. So we did all kinds of variations on the supply side.

On the demand side, we simulated different scenarios as well. What if for the 10 most-common illness, people [went to more] retail clinics? What happens if there are more retail clinics? What happens if there is more managed care? What happens if the ACA expands to all 50 states? The scenarios we look at are estimates to what would happen [to the] need for physicians in those various scenarios. We took all of those and on top of that we added in the U.S. census data on the aging of the population.

That was the formula we used last year and we vowed to continue to update it annually. We asked people for their critiques and then [updated our process] based on the concerns that people raised. There were two concerns out of last year. One was, "Did we appropriately identify the number in the rise of physician assistants?" We updated that process to get [a more accurate number]. The second critique was that we didn't count hospitalists who were trained in primary-care in our projections of primary-care doctors. We found a way using Medicare billing numbers to separate those primary-care doctors who were hospitalists.

We spend a lot of time to root this analysis in data that's been published that we can trace back. In our scenarios, we try to look at trends to tell us what may be the trend in five years to ten years.

PP: What specialty area is projected to be in greatest need in 2025?

JO: It's interesting, I think it's different than what we thought. We thought it'd be primary-care physicians as the biggest need, but it's surgical specialists. That was a surprise to all of us. Although the American College of Surgery has been talking about this shortage of certain types of surgeons.

PP: What did the simulation say about primary care?

JO: The shortage for primary care continues to exist. As we look at the different scenarios, we project a shortage of primary-care physicians between 14,900 and 35,600 physicians.

PP: Why does it get so much attention when people talk about physician shortages?

JO: I think that for most people, they have a tough time finding and being able to access a primary-care physician. When we took a look at this 10 years ago, the numbers were significantly higher. What we've seen since are nurse practitioners and physician assistants have grown in numbers and they have contributed to the workforce in primary care.

PP: How should this shortage be dealt with? What can we do to fix this situation?

JO: I think there are a couple of things we could do. When the shortage was first noted - 2000 and 2001 -we worked with medical schools to increase their enrollment. Over the last 10 to15 years, we have new medical schools and larger classes.

In order to be an independently practicing physician, you need to go to medical school, complete residency, and then you are deemed ready for independent practice. We need to increase residency programs. They have been frozen for the last 20 years. That's part of the log jam. We need to support more residency programs.

What we're also saying to Congress and the public ... "Let's have a modest increase in number of residents, like 3,000 per year for the next several years." Using technology, telemedicine, devices people wear, and team-based care ... between all of those things, we can be more efficient in the care we provide to people.

PP: Why do you think this shortage needs to be addressed now?

JO: When Medicare was funded in the 1960s, there was a part in the rule that said, "If we are going to give insurance to all these people, we need to make sure there are enough physicians trained in order to take care of them. That logic from the 1960s is the same logic now. We're expanding [the number of] insured people and Medicare is facing an increasing number of baby boomers who are aging. It's important that Congress and the American people keep their promise. They'll not only have Medicare, but they'll have sufficient physicians in order to access this care. It's a promise that started in 60s and 50 years later, we still have that commitment.